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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600176
Report Date: 04/04/2022
Date Signed: 05/12/2022 09:49:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2022 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220328152756
FACILITY NAME:HAILEY'S CARE HOMEFACILITY NUMBER:
075600176
ADMINISTRATOR:RIFORMO, MARIAFACILITY TYPE:
740
ADDRESS:3831 LA COLINA ROADTELEPHONE:
(510) 222-0945
CITY:EL SOBRANTESTATE: CAZIP CODE:
94803
CAPACITY:6CENSUS: 0DATE:
04/04/2022
ANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Licensee - Maria Riformo TIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 04/04/2022 at 9:25 AM Licensing Program Analyst (LPA) L. Holmes arrived announced to follow-up on an unannounced complaint visit from 04/01/2022 when LPA was informed by Licensee that the facility did not have any residents. LPA met with Licensee, Maria Riformo and Administrator, Matthew Riformo and explained the purpose of the visit.

During the course of investigation, LPA and Licensee discussed 3 residents, collected documents including but not limited to Admissions Agreement, ID/Emergency information and Preplacement Apprailsal Information. At 9:35 AM LPA asked Licensee did drop-off R1 at Kaiseer Richmond hospital and Licensee replied she called a transport for R1, The Administrator provided R1's cellular number for LPA to confirm or deny that R1 left willing. At 10:00 AM there was no answer when LPA called R1. LPA left a voicemail for R1. The complaint was received alleging illegal eviction. Based on record review, the eviction process does not meet the requirements of eviction notices under health and safety 1569.683.
...continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20220328152756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
VISIT DATE: 04/04/2022
NARRATIVE
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...continued from LIC 9099

Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20220328152756
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HAILEY'S CARE HOME
FACILITY NUMBER: 075600176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2022
Section Cited
HSC
1569.683(a)
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1569.683 Eviction Notices...(a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident...In addition, the notice to quit shall include all of the following: This requirement was not met as evidenced by:
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Administrator agrees to review regulation and submit a self-certification letter to CCL by POC date of 04/11/2022
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Based on record review, Licensee did not comply with the regulation cited above. The notice did not follow appropriate steps established by which posed an immediate Health & Safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3